Global Lab for Innovation

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1 Global Lab for Innovation Innovation Profile IT for Cost-Effective Decision Making Cedars-Sinai Health System Clinical decision support and the Choosing Wisely guidelines are built into an Electronic Medical Record system to improve best practice adherence and reduce overutilization of medical resources. This results in savings for the health system and payers due to improvements in hospital length of stay, and reductions in labor costs and supplies. Information Technology that incorporates clinical decision support can improve the way health systems deliver care in a variety of ways. Programming Electronic Medical Record systems to include pre-approved clinical guidelines and criteria can help health systems avoid duplicate procedures and tests, provide alerts to care team members on approved best practices and improve patient-provider discussion and decision-making at the time of care. What it is Clinical decision support is built into an existing Electronic Medical Record system (EMR) to ensure physicians, nurses and other care partners use best practices in a wide range of health care areas at the organization s hospital and outpatient clinics. The EMR system incorporates the guidelines of Choosing Wisely, a United States-based health education campaign led by the American Board of Internal Medicine, that addresses the problem of overutilization of medical resources. The system contains information about approved best practices, ensures physicians know about advance directives, documents advance care planning discussions and provides alerts to care team members when they order tests or procedures that may be unnecessary or have potential adverse effects that should be discussed with the patient.

2 Problems addressed Ineffective, expensive and inefficient care; Risks related to unnecessary tests and procedures; Low reimbursement rates by Medi-Cal managed care payers can be offset by savings from more efficient care. How it works Cedars-Sinai began adding reports and documentation into its Epic EMR system in 2010 and began programming the system to include best practices alerts in The first alerts related to red blood cell transfusion and included several evidence-based recommendations including those from the American Association of Blood Banks. More than 400 clinical decision support elements, which included guidelines, best practices, alerts and reminders and criteria for stability for discharge, were added over a 13-month period. Cedars-Sinai also has programmed all 120 Choosing Wisely recommendations into its EMR and is the first hospital in the United States to fully implement them. The American Board of Internal Medicine plans to release another 150 Choosing Wisely recommendations in 2014 and Cedars-Sinai is poised to implement all of them beginning in April To support patient health in ambulatory care, Cedars-Sinai s EMR also will soon have a secure portal to provide a patient link, which will allow patients access to patient materials developed by Choosing Wisely in partnership with Consumer Reports. The system also uses criteria matching to create alerts for other medical orders, including 239 best practices for lab tests, bronchodilator use, physical therapy, occupational therapy evaluations and referrals and many other evidencebased areas. The system also gives physicians comparative/benchmark reports such as how many of their patients have advance directives compared to other physicians patients. Innovators Cedars-Sinai Health System Complexity (How complex are the organizational requirements) Complex. Full implementation and documented savings took nearly three years to achieve. The innovation began in 2010 using non-alert IT elements such as reports and documentation, and the full array of clinical decision support elements in the EMR went live in December The system continues to be expanded. Global Lab Profile 2

3 Savings Cedars-Sinai and payers experienced reductions in labor costs and supplies/products due to ineffective or unnecessary tests and significant savings in hospital length of stay improvements from best practices supported by clinical decision support. Other savings of about $5.3MM, not including LOS savings, were as follows: $1.4 MM savings from reductions in ICU utilization; $53K savings from reducing duplicate lab testing; $242K savings in reducing unnecessary duplicate imaging and ineffective imaging; $1.6MM savings in reducing inappropriate use of acute therapies (PT, OT, Speech Therapy); $1.04 MM in savings from reducing unnecessary pharmaceuticals (Xopenex, EPO, Albumin for IHD, anti-emetics in oncology, leukocyte growth factors); $866K due to reductions from ineffective and unnecessary respiratory therapy treatments. Access No safety net setting. Just over half of the 243 patients served to date were commercial. The balance were dualeligible, Medicare FFS, PPO and POS. Patient experience Impact on patient satisfaction has not been measured. Engagement The system is designed to improve patient-provider communication but impact has not yet been measured. Global Lab Profile 3

4 Outcomes Positive. Internal data demonstrate the reduction of several duplicate tests and procedures that expose patients to unnecessary risks and potential adverse effects: 22 percent reduction in duplicate lab testing resulting in more than a 5 percent reduction in the average number of lab tests per patient day; 13 percent reduction in duplicate head imaging; 27 percent reduction in mean and 31 percent reduction in median initial antibiotic time to administration for sepsis. Sepsis Mortality Index decreased 0.33 points (from 4 months prior to 4 months after the alert); More than 72 percent reduction in inpatient orders for Gastric Emptying; 73 percent decrease in chest physiotherapy treatments; 67 percent increase in pneumonia patients discharged when stable; 20 percent reduction in cost/patient of Albumin for IDH post implementation of clinical decision support; 21 percent reduction of RBC transfusions on eight pilot sites four months before compared with 4 month post-implementation of the alert; PT has seen appropriateness of referrals increase from 80 percent to 99 percent, a 24 percent change; PT referrals seen within 24 hours has increased from 72 percent to 79 percent, a 10 percent change; OT screens reduced from 15 percent to 9 percent, representing a 40 percent decrease in screens; Appropriate OT referrals have increased from 85 percent to 91 percent, representing a 7 percent change. Spread Very scalable. Many EMR systems include decision support tools; plus Choosing Wisely is a broad national initiative. Cedars-Sinai is planning to expand the use of this approach. Stability Criteria for Discharge for key conditions is also highly scalable. Global Lab Profile 4

5 Barriers and Drivers Barriers Costs: There is substantial cost for programming new criteria into an EHR system, which may make this more difficult for some safety net providers. No other barriers to duplicating in safety net populations have been identified, since the approach is payer-neutral. Drivers Policy: Payers are eliminating compensation for procedures and practices deemed duplicative or unnecessary. Value: Increased efficiency makes a health system better positioned to contract with Medi-Cal managed care payers such as L.A. Care and Health Net, where reimbursement rates are relatively low. Similar innovations Other providers use Clinical Decision Support tools provided in the Epic EMR for a variety of purposes but none fully implement Choosing Wisely recommendations. Innovation contact Jennifer Kozakowski, Director, Clinical Innovation, Cedars Sinai Health System Address Original Date of Post July 2013 Global Lab Profile 5

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